Provider Demographics
NPI:1376587980
Name:WOLFE, JACINDA LEA (PA-C)
Entity Type:Individual
Prefix:
First Name:JACINDA
Middle Name:LEA
Last Name:WOLFE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 365B
Mailing Address - Street 2:
Mailing Address - City:FLEMINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:26347-9603
Mailing Address - Country:US
Mailing Address - Phone:304-623-7682
Mailing Address - Fax:
Practice Address - Street 1:VAMC
Practice Address - Street 2:1 MEDICAL CENTER DRIVE
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301
Practice Address - Country:US
Practice Address - Phone:304-623-3461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00926363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical